A METHOD OF TREATMENT OF

UPWARD DISLOCATION OF THE ACROMIAL END OF THE CLAVICLE*

GLOVER H. COPHER, M.D.

ST. LOUIS, MO.

U PWARD disIocation of the acromia1 a considerabIe space normahy present end of the cIavicIe occurs fairIy between the interarticuIar ends which frequentIy. In the case of a com- may seem to exceed the average separation

FIG. I. Pad of cotton and saddIer’s felt pIaced over disIocated end of cIavicIe and heId in pIace by adhe- sive pIaster.

pIete disIocation the acromia1 process of the scapuIa is forced downward and the coracoid process upwards, thereby rup- turing the coracocIavicuIar Iigament as we11 as the acromiocIavicuIar Iigaments, and disIocating the acromia1 end of the cIavicIe upward. When the traumatizing force is not great there is an incomplete disIocation.

Deformity is evident foIIowing this injury. There is a prominence visibIe at the acromiocIavicuIar joint and a drooping of the shouIder. Movements of the shouIder are Iimited and painfu1. The disIocation of the cIavicIe can be paIpated.

An x-ray picture of the acromiocIavicular joint may faiI to show a disIocation when the exposure of the fiIm is made with the patient rechning and tending to reduce the disIocation. In some patients there is

FIG. 2. EIastic bandage pIaced about shouIders under tension in figure of eight and in such a manner as to cover and compress pad and underIying disIocated end of cIavicIe. AxiIIae shouId be padded with cotton.

of I cm. It is evident that the most vaIuabIe diagnostic him is secured by making pictures of the injured and of the norma shouIder for comparison.

UsuaIIy the disIocation may be readiIy reduced by manipuIation. However, after the bones are approximated they are not easiIy heId firmIy in pIace unti1 heaIing of the joint has occurred. Inadequate retention of the reduction is IikeIy to resuIt in disabiIity due to the insecurity of the shouIder region when in motion.

To reduce the dislocation it is necessary to Iift the arm and scapuIa upward above their normaI IeveI, backward, and make sufficient downward pressure on the outer end of the cIavicIe to hoId it in pIace. Many procedures have been reported as giving satisfactory fixation. A common

* From the Department of Surgery, Washington University School of Medicine and Barnes HospitaI, St. Louis.

507

508 A merican Journal of Surgery Copher-DisIocation of CIavicIe DECEMBER, ICIXZ

method of attempting to immobiIize the shouIder in this position is by the use of a sIing or adhesive tape that passes around

FIG. 3. Arm on injured side pIaced in sling to dispIace weight of extremity from shouIder and to lift scapuIa upwards.

underneath the eIbow of the injured side and crosses over the outer haIf of the cIavicIe. In this method the weight of the arm suppIies the downward traction on the cIavicIe, but in this manipuIation the entire shouIder is forced forward and downward, thus making for recurrence of the disIocation. Furthermore, the down- ward tension on the cIavicIe at the site of disIocation is reIaxed by movements of the arm and forearm. More effective tension on the cIavicIe can be made by joining two parts of an adhesive sIing together by a strong piece of rubber. Shaar’ appIies the tension in the same manner by the appIica- tion of a canvas spIint and rubber tubing traction. These methods of traction how- ever offer onIy partia1 contro1 and as in the first method described tend to force the shouIder forward and downward. DiIIehunt2 secures retention of the shouIder in position by incasing the arm of the affected side in a pIaster cast and attaching this cast to a pIaster jacket that encircIes the trunk.

The rationa position for fixation of 1 Shaar, C. M. Upward dislocation of acromia1 end of

cIavicIe. Treatment by elastic traction splint. J. A. M. A., gz: 2083, 1929.

2 DiIIehunt, R. B. Fixation of the acromio-cIavicuIar joint. Surg. Clin. N. America, 7: 1307, 1927.

the shouIder after reduction of an upward dislocation of the outer end of the cIavicIe is backward and upward. A simpIe and comfortabIe method of securing this posi- tion is accompIished by the use of an eIastic bandage pIaced about the shouIders in a figure of eight. Before the eIastic bandage is appIied a pad of cotton and saddIe feIt of I or 2 inch thickness and about 2 inches in diameter is pIaced over the outer end of the disIocated cIavicIe and heId in pIace by adhesive pIaster. (Fig. I .) The axiIIary foIds and spaces are padded with cotton for comfort and to absorb perspiration. The eIastic bandage is appIied fairIy tenseIy about the shouIders in the manner of a figure of eight and so as to make pressure on the pad overIying the outer end of the disIocated cIavicIe. It is desirabIe to use a bandage containing rubber. The eIastic bandage puIIs the scapuIae and hence the acromion processes backward and upward and at the same time effectiveIy depresses the pad and the disIocated end of the cIavicIe. (Fig. 2.)

The bandage is prevented from sIipping by the insertion of safety pins at points where the bandage crosses itseIf. The tension of the eIastic bandage is made more effective by pIacing the forearm on the injured side in a fairIy tight sIing. The sIing dispIaces the weight of the extremity from the shouIder to about the neck and heIps to eIevate the shouIder above its normaI IeveI. (Fig. 3.) An axiIIary pad is used to prevent inward dispIacement of the shouIder.

Fixation by this means shouId be made for four to six weeks. The eIastic bandage can be removed occasionaIIy to aIIow tightening when repIaced and to permit cIeansing and powdering of the parts. After the use of the eIastic bandage is discontinued the arm shouId be carried in a sIing unti1 compIete heaIing has occurred. This method of fixation has been used satisfactoriIy on patients and it is beIieved that it wiI1 materiaIIy reduce the number of patients on whom it is necessary to perform an open operation for cure of the disIocation by arthrodesis, fixation by suture or by other means.